Provider Demographics
NPI:1366629453
Name:VICNIK TRANSPORTATION.
Entity Type:Organization
Organization Name:VICNIK TRANSPORTATION.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:OLUSEGUN
Authorized Official - Last Name:OGUNBANWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-568-6203
Mailing Address - Street 1:3701 66TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1815
Mailing Address - Country:US
Mailing Address - Phone:763-568-6203
Mailing Address - Fax:763-780-7175
Practice Address - Street 1:3701 66TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1815
Practice Address - Country:US
Practice Address - Phone:763-568-6203
Practice Address - Fax:763-780-7175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN373258343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)